Bravo Performing Arts Summer Program Sponsored By: Kuumba Ensemble Heritage House Community Theater

Program Medical Release Form 2017

Life Builders Church – 200 N. Central Ave., Baltimore, MD 21202 -Former Sojourner Douglass College Campus (Contact Phone#:) 443-413-1470 Performing Arts Administrator: Rosalyn M. Gaines

Website -www.kuumbaensemble.org

The proposed activities provided by the Bravo Performing Arts Program may require participation in some physical exercises that could be physically demanding. Many of the activities will challenge students, and cause surges in blood pressure and pulse rates. Therefore, all participants must be free of medical or physical conditions, and heart related or other diseases, which might create undue risk to themselves or any others that depend on them. Good physical condition will increase your enjoyment of all activities. If there is any doubt about your child’s ability to safely participate in all program activities, you should have a physical examination and get a release signed by your physician. Please know that the program administration reserves the right to deny participation to anyone for any reason.

Name: ______

Date of Birth: ______

Address: ______

Gender: ______

City/State/Zip: ______

Age: ______

Work Phone: ______Home Phone: ______

Cell Phone: ______

Name of Physician/ Phone: ______

Date of last physical examination:______

EMERGENCY CONTACT: In case of emergency, notify ______Relationship: ______

Home Address: ______City/State/Zip: ______

Work Phone: ______Home Phone: ______

Cell Phone: ______

MEDICATIONS: List all current medications taken, prescribed dosage, and the frequency of dosage. Attach a separate sheet if necessary.

Please know that we can only assist with asthma inhalers or emergency meds that must be carried at all times, however they must be reported and listed on this form.

Current medication: 1) ______Prescribed Dosage: ______Frequency: ______Current medication: 2) ______Prescribed Dosage: ______Frequency: ______Current medication: 3) ______Prescribed Dosage: ______Frequency: ______

HEALTH HISTORY: Check any and all conditions that apply and explain in detail. Attach a separate sheet if necessary.

Allergies (please specify any and all below), ______

Diabetes___, Arthritis/Joint Problems___, Heart Problems____, High Blood Pressure____, Asthma____, Seizures____, Hypertension___, Bleeding Disorder_____, Thyroid____, Kidney___, Epilepsy___, Recent Operations/Injuries___, Disability/Chronic Recurring Illness____, Dietary Restrictions______Other: ______Please explain condition(s) in detail: ______

IMMUNIZATION RECORDS: Maryland state law requires this form to have a current & correct immunization record for anyone under the age of 18 attending the program. Please check and fill in the exact dates for each of the following immunizations or attach a current shot record. DPT/DT Date: __/__/__ Polio Date: __/__/__ MMR Date: __/__/__ TB Date: __/__/__ Other Date: __/__/__ (Only if applicable) I have chosen to not have my child immunized: (Parent/Guardian Signature) ______

PERSONAL INSURANCE INFORMATION: Please provide a photocopy of your insurance card. In case of emergency, personal insurance would cover as primary and program insurance would cover as secondary.

Insurance Carrier: ______Policy #: ______Group #: ______Suggestions or other health-related information: ______

General Health Statement: ______

REPRESENTATION AND EMERGENCY AUTHORIZATION:

I ______acknowledge the above information is correct to the best of my knowledge. And I believe my child’s health is satisfactory to participate in all program activities including, but not limited to Hip-Hop dance, modern dance, stepping, or any and all other performing arts classes. Furthermore, I give permission to the Bravo Performing Arts Program management, trained CPR/First-aid activity facilitators, and or hospital medical staff, to provide medical treatment that may be deemed necessary to insure the well-being of the named attendee/participant.

______Signature of Parent or Guardian (if Attendee/Participant is under 18)

Date______